Provider Demographics
NPI:1790333656
Name:FUNK, BRITTANY (COTA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62932-1001
Mailing Address - Country:US
Mailing Address - Phone:618-318-3262
Mailing Address - Fax:
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:855-608-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant